Psychosomatic Symptoms

“You think? I mean, yeah, I am anxious, but it feels more like it’s from the symptom than causing the symptom.”

“Still.”

My colleague and friend—and physician—and I were discussing the sudden onset of intense nausea I’d started to experience roughly three weeks after I’d been released from the hospital, as I detailed in a previous post, Overcoming The Fear Of Death. After a pulmonary embolus I’d been left dealing with a clostridium difficile infection, for which I was taking Flagyl, a drug known to cause nausea. The only problem with concluding that the drug was the cause of mine was that I’d been on it nausea-free for a full week already, not to mention I’d been on it previously without nausea for a full course the first time we’d treated the clostridium difficile infection (I’d relapsed, as commonly happens). Why after a previous full course and then seven days would it suddenly cause this side effect?

It wouldn’t. Side effects from medications almost always manifest as soon as a drug reaches its therapeutic level in a person’s bloodstream, if not sooner. This is rarely more than a few days for antibiotics.

The nausea was so intense I could hardly move. When I was a child and had felt nervous, I’d sometimes develop an upset stomach—an extreme version of “butterflies”—but the intensity of what I was feeling now was several times what I’d felt then—or have felt since. In the past, I’d always been able to tell how my nervousness was connected to whatever minor physical symptom it had produced, whether that symptom was sweating, flushing, palpitations, or those classic “butterflies.” But I sensed no connection between my anxiety and my nausea at all.

But I told my friend and doctor that I was open to the possibility that he was right. He suggested I talk with a psychiatrist who specialized in anxiety disorders, which I did the next day. He, in turn, diagnosed me with mild PTSD and put me on clonazepam, a long-acting anti-anxiety medication.

My nausea vanished after only one dose. I was astounded. I thought I’d known myself and my body’s reactions intimately well and yet this took me completely by surprise. That clonazepam had resolved my nausea proved to me the cause of the nausea had indeed been anxiety.

WHAT IS SOMATIZATION?

Somatization is defined as the tendency to experience psychological distress in the form of physical symptoms. Astoundingly, in one study of 1000 patients presenting over a 3-year period with 567 new complaints of 14 common symptoms (including chest pain, fatigue, dizziness, headache, edema, back pain, shortness of breath, insomnia, abdominal pain, numbness, impotence, weight loss, cough, and constipation) a physical cause was found only 16% of the time. This doesn’t mean that only 16% of all these complaints had a physical cause and the other 84% had a psychosomatic cause; rather, it means that 84% of the symptoms had no known physical cause. We still don’t know what causes migraines, for example, but that doesn’t mean we should conclude migraines have only a psychological cause.

On the other hand, another study suggested that as many as 20% of patients who present to primary care doctors are experiencing physical symptoms that have a purely psychological cause. What’s fascinating to me about this aren’t the various characteristics that circle somatization—some of which include a predisposition to amplify symptoms, the potential benefits of playing the sick role, the emotional effects of trauma, and denial—but that somatization happens at all.

On one level, of course, the brain and the body are intimately intertwined, the brain sending out innumerable signals and instructions to the body every second, the body receiving them and sending back perhaps just as many. In Buddhism, the mind and body are considered “two but not two,” a concept meant at least partially to reflect their complex interdependence. Further, evidence is beginning to mount that our physical brains and our subjective experience of them—that is, our minds—are also “two but not two” (as I discussed in a previous post, The True Cause Of Depression), so the idea that an emotional disturbance could be translated into a physical symptom shouldn’t be too surprising.

And yet it often is. I’ve not only read about conversion disorders (where the pain from an intense emotional trauma too awful to face becomes “converted” into a paralyzed limb, a paralyzed voice, or, paradoxically, an inability to stop moving a limb or limbs)—I’ve seen and cared for them myself. And yet when my nausea was shown to have a purely psychological cause, I still had a hard time accepting it. It took incontrovertible proof to bring me to acceptance. But then from acceptance came awe—awe at the power inherent in my own mind.

Why, I chastised myself, would I have thought an anxiety as intense as mine would have been confined only to my mind? I, who have a greater understanding of the interconnectedness of mind and body than most people should have known better. I suppose it only goes to prove, once again, that intellectual understanding is one thing and experience quite another.

Now I’m not only more cognizant how often symptoms I see in my patients are likely psychosomatic but more sympathetic to their resistance to that idea. Couple those two facts with a third, that most physical symptoms do have a physical cause, and the business of sorting out any symptom shows itself to be a tricky one indeed.

So tricky that I worry when patients try to sort it out themselves without a doctor’s help. The chest pain you’re having could be due to stress—you and I may both want to believe it is (you especially, explaining why you delayed coming to see me until it passed a certain threshold of intensity), but it could just as easily be a heart attack. The specific details surrounding it need to be pored over carefully to distinguish between the two. No degree of certainty that you “know your own body” can deliver the diagnosis definitively—a refrain I hear many times which, though sometimes accurate, more often in my experience is not.

Yet even when a patient accepts their symptom is being caused by an emotion—an exceptionally difficult barrier to surmount—the trauma that caused the symptom in the first place is often shown to be so ugly that both patient and doctor can readily understand why the patient’s mind converted it into a physical symptom in the first place: even the mind itself believed the emotional trauma to be easier to handle that way. Physical symptoms often get better with a pill. Emotional traumas often take years to heal—if even then. The technology we have to heal the scars caused by some traumas—as advanced and helpful as psychology can be—still lags behind the technology we have to treat ailments with purely physical causes.

But we shouldn’t be discouraged. We may all experience psychosomatic symptoms to some degree, but when our symptoms are shown to be so and we accept it, that acceptance becomes the most important step toward resolving them. After all, how can we find a contact lens we lost by looking near a lamppost when we lost it in the shadows? The real work begins, of course, once we start looking in the right place. Dealing with somatization only requires us to bring to the table one quality: courage. (Though here I have to sound an important caution: when faced with a symptom they can’t readily explain by physical means, many doctors will reflexively turn to somatization as the explanation without bothering to unearth what experience or emotion might be causing it, as I wrote about in a previous post, When Doctors Don’t Know What’s Wrong).

I was on clonazepam for several months and then gradually tapered off it as the proximity of my brush with death receded. I haven’t yet resolved the questions it raised but am no longer plagued by the immediacy of my fear of death—and therefore no longer by the intense anxiety it stirred up. I fully recognize that I may spend the rest of my life trying to make peace with the fact that I’m mortal and yet never do it. But what else is there to do—what else is there for any of us do—but battle our demons to the death, either theirs or ours?

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I believe the question about reincarnation may be equivalent to the physics question of whether the universe is infinite, or there are an infinite number of universes. With such an infinite amount of space-time, if that space-time supports a non-zero probability of the existence of chemical elements analogous to those we currently have, then we will all reoccur an infinite number of times in many variations.

But I suspect that we cannot know the answer to this physics question—it may be impossible for a finite creature existing within a universe to know the answer to the question of the infinity of the universe or the existence of other universes. This may be related to Godel’s theorem which shows for a mathematical language that “there are true statements expressible in its language that are unprovable.”

Alex, I’m a little uncomfortable with this article. I just keep thinking about the article you wrote “When Doctor’s Don’t Know What’s Wrong.” I just had so many experiences where the docs didn’t know what was wrong, told me it was psychosomatic, and then eventually an explanation came to light and it wasn’t psychosomatic at all. I am very glad that you got better after taking an anti-anxiety med but it isn’t always as easy as that. And it isn’t true that side effects to meds are always apparent toward the beginning of treatment.

My most recent psychosomatic dx came after I had symptoms including episodes of inability to talk, depression, confusion, visual disturbances including double vision, and loss of use of my legs. I also went to see a psychiatrist. I didn’t really care what caused the symptoms. I just wanted to get better and if a psychiatrist could help, fine. But the psychiatrist didn’t help me.

One day I came across an article describing basilar type migraines and my symptoms were described therein. I consulted a neurologist who specializes in headache and whom I had consulted years before. He is also a psychiatrist, incidentally. He told me he didn’t think that my problem was psychosomatic, that it did fit the profile of basilar type migraine but that one doesn’t usually begin to present with basilar type migraine at my age (55). I did a little more research and I found that oral contraceptives can trigger BTM. I wasn’t taking oral contraceptives but I had been taking Tamoxifen for 3 years which in some ways is similar to oral contraceptives. When I told the neurologist about the Tamoxifen, he told me that all his patient who took Tamoxifen, experienced exacerbat90j of their migraine.

I stopped taking Tamoxifen and the symptoms also stopped. The longer I took Tamoxifen, the worse the symptoms were. I think there was a cumulative effect.

I’m not saying that psychosomatic illness is a myth. I certainly have experienced butterflies in my stomach before an exam and other similar phenomena but I think doctors frequently default to the psychosomatic dx when they are stumped and this is dangerous and upsetting for the patient.

Helen: No disagreement with your last statement, as you know from reading When Doctors Don’t Know What’s Wrong. My point in writing this post was that psychosomatic symptoms are real and make the diagnosing of perplexing symptoms especially difficult. A good physician knows the typical ways psychosomatic symptoms present and thinks of somatization as last possibility, not a first.

Did a quick search on clonazepam and antiemetics and found that clonazepem has been used successfully as an antiemitic in chemotherapy-induced nausea and vomiting “warranting further investigation.” For example: Clonazepam for Chemotherapy-induced Nausea and Vomiting (CINV) at http://ar.iiarjournals.org/content/28/4C/2433.short.

Also, in the search, the use of benzodiazepines for nausea associated with vertigo was mentioned.

Joan: No question that benzodiazepines can have a beneficial effect on nausea from causes other than anxiety. Just turned out that wasn’t the case with mine.

As a physician-survivor, I wrote a first-person article for clinicians about anxiety-induced symptoms. You can find the article entitled “Visualizing the Buzz” in Oncology Times at http://tinyurl.com/OT-Buzz I hope you find it useful.

I have experienced the manifestation of mental distress in my body numerous times. I am sad to say that before I found my voice, bodily symptoms were a way to avoid or “get out of” certain distasteful situations. I still see it happening today, so I know mind and body are inextricably interwoven.

It is amazing to me that MD’s still cleave to the Cartesian dualism. The neck is not some cutoff point—yet, we have psychiatrists and GP’s. Strange to me that the impasse still exists.

One particularly egregious memory comes to mind: in college, I had an unusual onset of numbness in my pelvic region. At the neurologist’s, I told the nurse I was in a domestic violence situation, and wondered if there might not be some connection.

When the doctor came in he smirked at me: “Do you REALLY think the mind has anything to do with the body?” I was hotly ashamed and furious at such stupidity and insensitivity.

Lisa: That’s a terrible story. I still find myself amazed when I hear about doctors saying things like that to patients.

At the risk of sounding very Southern Californian, a combination of chanting, a strong practice, power yoga at least 3 times a week, deep breathing and a vegan/raw food diet has eliminated most of it for me.

I had a c. difficile infection earlier this year, and had to take a much stronger antibiotic, Vancomycin, to be rid of it. Flagyl didn’t touch it. I had moderate nausea from the c. difficile along with all the other fun stuff it brings.

I agree with Helen. I loved the post and the ideas about how our mind affects our bodies. At the same time, I’m intensely sensitive to the fact that my doctor absolutely cannot help me with a number of minor chronic physical ailments. When I had injured my shoulder such that I could not raise it above horizontal there was nothing that could help me but time. It’s dangerous to think that my doctor knows more about my body than I do; they can only make suggestions.

A recent situation comes to mind. My son, now 17, had gastrointestinal problems since a child, essentially chronic—stomach cramping and diarrhea, fairly frequent, sometimes incapacitating, leading to many days of missed school. I brought the issue up to the pediatricians multiple times over the years. I usually received the blank stare in response with the insinuation that this is not really a medical problem, rather one of nerves. One of them finally said IBS and said to increase fiber. Finally after years of symptoms was referred to a GI who did reams of labs and found an elevated folate level; the plan was to “blast” his colon with an antibiotic neomycin then start probiotics and also rx’d lebsin for cramping episodes. After two days on the antibiotic he had two days of severe diarrhea and missed two days of school. I was fed up. Took him to an herbologist, a practitioner of natural medicine. After one visit, six months ago, he has never had another symptom, after YEARS of unending chronic symptoms. He was given two types of probiotics and peppermint oil twice a day for the abdominal cramping. That was a lifetime of GI symptoms cleared up in one visit!!! And in conclusion, I would like to say that I believe that my sons issues were considered psychosomatic for years, and that if he continued the way he did he would have had a lifetime of these issues and eventually would have developed severe chronic issues including Crohn’s disease.

Joan: No question in today’s modern era when medicine and science are expected to have all the answers, not just by patients but by doctors as well, that doctors often inappropriately turn to somatization when they can’t figure out a particular symptom or set of symptoms, as I wrote about in an earlier post, When Doctors Don’t Know What’s Wrong. The trick is figuring out when something is psychosomatic and when it has a physical cause we just can’t figure out. I’m glad your son is better.

I’ve had full-on allergic reaction to an antibiotic on the 9th day of treatment (levaquin with flagyl for diverticulitis). I felt ill and very bad through the whole course, but not in a way that I could identify as an allergic response, until day 9, when I woke up with swollen eyes and face, and hives on my torso. Thankfully my doctor let me skip the last day.

I also took cipro and felt similarly bad the whole time.

Elaine: As one of my colleagues puts it, that many antibiotics make you feel bad (even without causing allergic reactions) is one of medicine’s dirty secrets.

I appreciate the info in your post, and agree that the mind-body connection is often misunderstood. I’m also glad the clonazapam helped you. I’m not sure, however, that the symptom relief you experienced “proves” that anxiety was the cause of those symptoms. As other commenters have pointed out, 1) clonazapam is not just an anti-anxiety med; it is also used to treat nausea from other medications, and 2) medication side-effects do not always occur early in treatment; steroids like prednisone are a good example.

My own experience with flagyl is that the first 5 or 6 days were ok, and then the killer nausea hit on day 6 or 7. So although I find your post useful and insightful, I question your conclusions about your nausea; this seems like a pretty clear case of flagyl nausea—a well-known side effect.

Ann: The infectious disease doctors who were treating me for the clostridium difficile infection thought so too. But, 1) 7 days is more than enough time for the drug levels to have reached steady state in my system, the point by which most side effects (certainly from antibiotics) have already appeared (your point about the long-term affects of prednisone is well taken, but that’s a hormone and is really the exception to the rule of most drug side effects) and 2) I already been on flagyl once before for the c.diff (I then relapsed and had to go back on it again) and the first time around I felt no nausea at all.

I do think that we’ve most of us been culturally inoculated not just with the Cartesian dualism to which Lisa refers but also with the notion that there’s something illegitimate and even fake about disorders of psychogenic origin—that if that’s the cause, you’re not really sick. Both doctors and patients have a hard time avoiding that fallacy—certainly as patients, we know that there’s something really wrong, and we can have a hard time accepting that a psychosomatic disorder is still something “really wrong.” (Elaine Showalter’s Hystories is a fascinating book for examining that phenomenon). Funny that we’re a little more respectful of “stress-induced,” which isn’t all that different.

It doesn’t help that many doctors have, in the past, acted as if “psychosomatic” were a magic word that allowed them to wash their hands of a patient’s problem without having to confess that they’re stumped. I have an admirable friend who, when told by a doctor that her pain was all in her head, cheerfully and sensibly said “Okay—then let’s fix my head.” I’m really cheered that your colleague, unlike her doctor, apparently considered that quite a reasonable prospect that was well within medical reach, and I think we’d probably all benefit from so matter-of-factly approaching it.

I just want to add a somataform/conversion disorder symptom that is more common than people know, and that is seizures. On December 28th, 2009 I began having very violent seizures and 20 or more a day. My last seizure was more than a week ago, when I finally began chanting for no more seizures rather than being on the fence about having them. Even before this, my seizure count and their intensity had gone down. For months, I have been living with them, and taking part in a clinical trial for psychogenic non-epileptic seizures since the beginning of February. You can find out more from an experience I gave here:

When I finally met doctors that knew what was going on—they told me that 30% of patients seen in their epilepsy center in NYC have non-epileptic seizures. That’s a large number. The doctor who ran the clinical trial also noted a statistic similar, and also said that psychogenic seizures can show themselves in every way that normal epileptic seizures can—from full grand mal-types, to a single limb shaking. I can tell you from experience that conversion disorders exist and are an incredible journey to heal.

In my experience, some doctor’s simply don’t know how to tread into the multi-faceted arena that a psychosomatic display would require. Just some more info—don’t rule out conversion disorders or psychosomatic symptoms.

I tend to agree with your post, Alex. I’ve been experiencing psychosomatic disorders all my life. Whenever a relative or friend had symptoms of whatever disease they might be fighting I seemed to develop the same symptoms; until I found out for sure through medical tests that everything was okay was when the symptoms seemed to disappear. I believe the mind is a powerful tool and can convince you that something is wrong when it really isn’t. Thank you, Alex, for your explanation on psychosomatic disorder because I think it will finally clear the road for my so called phantom pains.

Where is this objective proof of somatization, because I’ve never seen any.

If I took a “somatizing” patient and claimed invisible aliens are the true cause of the symptoms, and didn’t demonstrate my claim in anyway, what would you think of my diagnosis?

John: Self-observation provides ample subjective proof: the phenomenon of experiencing “butterflies” in the stomach before speaking, for example, is so stereotypically reproducible in so many people, both appearing and resolving with anxiety so tightly, that we can reliably link the two causally.